Clinical presentation, management and outcomes of gastrointestinal stromal tumors

Gastrointestinal stromal tumor in North Africa and the middle east: updates in presentation and management from an 11-year retrospective cohort

OBJECTIVES

This study described the epidemiological, clinical, and survival profiles of patients with gastrointestinal stromal tumor (GIST) in North Africa and the Middle East (AfME).

METHODS

This regional, multicenter, observational, retrospective study collected 11-year data on demographics, medical history, disease characteristics, current treatment approaches of GIST, the safety of the most common tyrosine kinase inhibitors (TKIs), second cancers, and survival status.

RESULTS

Data of 201 eligible patients were analyzed: mean age was 56.9 ± 12.6 years; 111 (55.2%) patients were men, 21 (10.4%) patients had previous personal malignancy. The most common clinical presentation of GIST was dysphagia [92 (45.8%) patients]. The stomach was the most common primary site in 120 (60.7%) patients, 171 (85.1%) patients had localized disease at diagnosis. 198 (98.5%) GIST cases were CD117/CD34-positive. Imatinib was used in the neoadjuvant (18/21 patients), adjuvant (85/89 patients), and first-line metastatic treatment (28/33 patients) settings. The most common non-hematological toxicity associated with TKIs was vomiting in 32/85 (37.6%) patients. Overall, 100 (49.8%) patients (95%CI: 42.8-56.7%) were alive and disease-free while 30 (14.9%) patients were alive with active disease.

CONCLUSION

Presentation of GIST in our AfME population is consistent with global reports, being more frequent in patients >50 years old and having the stomach as the most common primary site. Unlike what is usually reported, though, we did have more patients with lymphatic spread of the disease. Despite the global trend and advances in the treatment of GIST according to molecular profile, this is still far to happen in our population given the lack of access to molecular profiles and the high associated cost.

Correlation Between Tumor Volume and Hemoglobin Level in Gastrointestinal Stromal Tumor

INTRODUCTION

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors. Anemia is a common finding in GIST, but the relationship between tumor volume and anemia severity is not well established.

METHODS

This study aimed to investigate the correlation between the severity of anemia and various factors, mainly tumor volume, in GIST patients who underwent surgical resection. The study included 20 patients with GIST who underwent surgical resection at a tertiary care center. Demographic data, clinical presentation, hemoglobin level, radiological findings, surgical procedure, tumor characteristics, pathological findings, and immunohistochemical analysis were recorded. The tumor volume was calculated from the final resected tumor dimensions.

RESULTS

The mean age of the patients was 53.8 ± 12 years. Eleven were males, and nine were females. The most common presentation was upper gastrointestinal bleeding (50%), followed by pain in the abdomen (35%). The most common tumor location was the stomach (75%). The mean hemoglobin level was 10.29 ± 1.9 g/dL. The mean tumor volume was 470.8 ± 1269.07 cc. R0 resection was achieved in 18 (90%) patients. There was no significant correlation between tumor volume and hemoglobin level (r=0.227, p=0.358).

CONCLUSION

This study found no significant correlation between tumor volume and the severity of anemia in patients with GIST. Further studies with larger sample sizes are needed to validate these findings.

Development and Validation of Artificial-Intelligence-Based Radiomics Model Using Computed Tomography Features for Preoperative Risk Stratification of Gastrointestinal Stromal Tumors

BACKGROUND

preoperative risk assessment of gastrointestinal stromal tumors (GISTS) is required for optimal and personalized treatment planning. Radiomics features are promising tools to predict risk assessment. The purpose of this study is to develop and validate an artificial intelligence classification algorithm, based on CT features, to define GIST's prognosis as determined by the Miettinen classification.

METHODS

patients with histological diagnosis of GIST and CT studies were retrospectively enrolled. Eight morphologic and 30 texture CT features were extracted from each tumor and combined to obtain three models (morphologic, texture and combined). Data were analyzed using a machine learning classification (WEKA). For each classification process, sensitivity, specificity, accuracy and area under the curve were evaluated. Inter- and intra-reader agreement were also calculated.

RESULTS

52 patients were evaluated. In the validation population, highest performances were obtained by the combined model (SE 85.7%, SP 90.9%, ACC 88.8%, and AUC 0.954) followed by the morphologic (SE 66.6%, SP 81.8%, ACC 76.4%, and AUC 0.742) and texture (SE 50%, SP 72.7%, ACC 64.7%, and AUC 0.613) models. Reproducibility was high of all manual evaluations.

CONCLUSIONS

the AI-based radiomics model using a CT feature demonstrates good predictive performance for preoperative risk stratification of GISTs.

Gastro-intestinal stromal tumor (GIST): Experience from a tertiary care center in a low resource country

Objectives

The aim of this retrospective study was to review the overall survival (OS) and disease-free survival (DFS) of GISTs treated surgically at our center over the past decade.

Material and Methods

We undertook a 12-year retrospective review of our experience in treating this condition with a focus on long-term outcomes of treated patients in a resource-constrained environment. Incomplete follow-up information continues to be a major problem with studies conducted in low resource settings, and in order to overcome this, we undertook telephonic contact with patients or their relatives to get the necessary information about their clinical status.

Results

Fifty-seven patients with GIST underwent surgical resection during this period of time. The stomach was the most common organ involved in the disease, with 74% of the patients. Surgical resection was the main treatment approach, with R0 resection possible in 88%. Nine percent of the patients were given Imatinib as neoadjuvant treatment and 61% were offered the same, as adjuvant therapy. The duration of adjuvant treatment changed from one year to three years over the study period. Pathological risk assessment categorized the patients as Stage I, 33%; Stage II, 19%; Stage III, 39%; and Stage IV, 9%. Of the 40 patients who were at least three years from surgery, 35 were traceable giving an 87.5%, overall three-year survival. Thirty-one patients (77.5%) were confirmed to be disease-free at three years.

Conclusion

This is the first report of mid-long-term outcomes of the multimodality treatment of GIST from Pakistan. Upfront surgery continues to be the main modality. OS & DFS in resource-poor environments can be similar to those seen in a better-structured healthcare setting.

Comparison of safety and short-term outcomes between endoscopic and laparoscopic resections of gastric gastrointestinal stromal tumors with a diameter of 2-5 cm

BACKGROUND AND AIM

Developments of endoscopic techniques brought the possibility of endoscopic resection for gastrointestinal stromal tumors (GISTs) of larger sizes. We aim to compare safety and short-term outcomes between endoscopic and laparoscopic resections of gastric GISTs with a diameter of 2-5 cm.

METHODS

This is a single-center, retrospective cohort study. The clinical data, perioperative conditions, and the adverse events of patients who underwent endoscopic or laparoscopic resection for gastric GIST of 2-5 cm in Zhongshan Hospital, Fudan University, from January 2016 to December 2020 were retrospectively reviewed.

RESULTS

A total of 346 patients were reviewed; 12 patients who failed to accomplish the planned procedure were excluded; 182 underwent laparoscopic resection; and 152 underwent endoscopic resection. Significant differences exist in the tumor size between the laparoscopic group (3.43 ± 0.86 cm) and the endoscopic group (2.78 ± 0.73 cm) (P < 0.01). Compared with laparoscopic resection, endoscopic resection was associated with faster recovery (P < 0.01), shorter hospital stays (P < 0.01), and lower cost (P < 0.01). The incidence of Clavien-Dindo grade II-V adverse events in the endoscopic group (3/152) was significantly lower than that in the laparoscopic group (12/182) (P = 0.04). After a propensity score matching analysis, the endoscopic group showed similar incidences of complications with the laparoscopic group, while the advantages over laparoscopic resection in postoperative hospital stay, time to first oral intake, and hospitalization expenses remained significant (P < 0.01).

CONCLUSIONS

Endoscopic resection is a safe and cost-effective method for 2-5 cm of gastric GISTs compared with laparoscopic resection.

Clinicopathological Features and Outcomes of Gastrointestinal Stromal Tumours in Oman: A multi-centre study

Objectives

This study aimed to report the clinicopathological features, management and long-term outcomes of patients with gastrointestinal stromal tumours (GISTs) in Oman.

Methods

This retrospective study was conducted on patients treated for GIST between January 2003 and December 2017 at three tertiary referral centres in Muscat, Oman. All patients with confirmed histopathological diagnoses of GIST and followed-up at the centres during this period were included. Relevant information was retrieved from hospital records until April 2019.

Results

A total of 44 patients were included in the study. The median age was 55.5 years and 56.8% were female. The most common primary site of disease was the stomach (63.6%) followed by the jejunum/ileum (18.2%). Two patients (4.5%) had c-Kit-negative, discovered on GIST-1-positive disease. A total of 24 patients (54.5%) presented with localised disease and eight (33.3%) were classified as being at high risk of relapse. Patients with metastatic disease received imatinib in a palliative setting, whereas those with completely resected disease in the intermediate and high-risk groups were treated with adjuvant imatinib. Of the six patients (13.6%) with progressive metastatic disease, of which four had mutations on exon 11 and one on exon 9, while one had wild-type disease. Overall, rates of progression-free survival and overall survival (OS) at 100 months were 77.4% and 80.4%, respectively. Rates of OS for patients with localised and metastatic disease were 89.9% and 80.2%, respectively.

Conclusion

The presenting features and outcomes of patients with GISTs in Oman were comparable to those reported in the regional and international literature.

A concealed inguinal presentation of a gastrointestinal stromal tumor (GIST): a case report and literature review

BACKGROUND

Gastrointestinal stromal tumor (GIST) can arise anyplace along the gastrointestinal (GI) tract. The uncommon tumor location in groin area is rarely reported.

CASE PRESENTATION

We herein reported a metastasized case presented as GI hemorrhage complicated with indirect hernia, and underwent tumor cytoreduction, herniorrhaphy and chemotherapy for jejunal GIST. The case was described consecutively based on the process of surgical management, with a good follow-up result. A literature review by searching similar case reports from two national medical databases was performed to summarize clinical features of such unusual presentation of GIST, which included hernia characteristics, short- and long-term outcomes of this disease. It showed GIST presenting as groin hernia was rarely reported and all available 11 cases suggested a primary tumor and required both tumor resection and hernia repair. The long-term results indicated 64.3% overall survival at 5 years after the incidental diagnosis.

CONCLUSIONS

Inguinal hernia is an extremely rare presentation of GIST, with limited case reports available in the literature. A radical involving tumor resection plus hernia repair is an optimal surgical approach for such uncommon condition. An adjuvant medication mounting on mutated KIT gene should be strictly followed for high risk cases.

Comprehensive review into the challenges of gastrointestinal tumors in the Gulf and Levant countries

Although gastrointestinal stromal tumors (GISTs) are rare, with an incidence of 1/100000 per year, they are the most common sarcomas in the peritoneal cavity. Despite considerable progress in the diagnosis and treatment of GIST, about half of all patients are estimated to experience recurrence. With only two drugs, sunitinib and regorafenib, approved by the Food and Drug Administration, selecting treatment options after imatinib failure and coordinating multidisciplinary care remain challenging. In addition, physicians across the Middle East face some additional and unique challenges such as lack of published local data from clinical trials, national disease registries and regional scientific research, limited access to treatment, lack of standardization of care, and limited access to mutational analysis. Although global guidelines set a framework for the management of GIST, there are no standard local guidelines to guide clinical practice in a resource-limited environment. Therefore, a group of 11 experienced medical oncologists from across the Gulf and Levant region, part of the Rare Tumors Gastrointestinal Group, met over a period of one year to conduct a narrative review of the management of GIST and to describe regional challenges and gaps in patient management as an essential step to proposing local clinical practice recommendations.

Gastrointestinal Stromal Tumours (GIST): A Review of Cases from Nigeria

PURPOSE

Gastrointestinal stromal tumours (GIST) are rare and studies on GIST in Nigeria are extremely uncommon. This study aims to achieve a comprehensive systematic review of the cases of this tumour in Nigerians.

METHODS

A systematic search of all available literature on GIST published from Nigeria between January 2000 and December 2018 was done and reviewed. Simple descriptive data on all the cases are presented.

RESULTS

The search yielded 15 publications but 13 publications with a total of 67 patients were analysed. The other two studies centred on imatinib therapy and overall survival, and molecular characteristics respectively and were therefore reviewed independently. Age at diagnosis ranged from 9 to 75 years, with mean age being in the 50s and 60s across most studies. There is no gender disparity. Anatomical location of primary tumours showed gastric location as the most frequent (61%) followed by large intestine accounting for 15%, the small intestine (9%) and other locations (15%). Tumour size ranged from 5-39.5 cm. Over 85% of patients had tumour size greater than 10 cm at presentation, hence fell into intermediate or high-risk group irrespective of location of tumour. The overall survival of a cohort of 27 patients that had imatinib therapy was 69.5% after 4 years of follow-up. KIT exon 11 mutations were the only mutations detected from a small cohort of 12 patients.

CONCLUSIONS

Characteristics of GIST in Nigerians are fairly similar to other parts of the world. However, most of our patients present with large masses which are of poor prognostic characteristics.

Overexpression of CD55 correlates with tumor progression and poor prognosis in gastric stromal tumors

Backgrounds: Accumulating evidences have demonstrated that CD55 can protect cells from complement-mediated attack, and is involved in tumor dedifferentiation, migration, invasiveness, and metastasis. However, the role of CD55 in gastrointestinal stromal tumors (GISTs) has not been investigated. Aims: Our study aimed to analyze the expression of CD55 in gastric GISTs and its correlations with clinicopathologic characteristics and prognosis. Materials and methods: A total of 118 gastric GIST patients were included in our study. CD55 expression in GIST tissue samples was evaluated using immunohistochemistry. Cumulative survival was conducted using the Kaplan-Meier method. Cox regression analyses were performed to identify factors associated with progression-free survival (PFS) for patients with gastric GISTs. Results: Of 118 gastric GISTs patients included in our study, 44 (37.3%) were positive for CD55 expression. Positive CD55 expression in gastric GISTs was closely associated with tumor size (13.52±7.35 vs 5.07±1.90 cm, respectively; P<0.001), Ki 67 labeling index (P=0.001), mitotic counts (P=0.005), NIH risk classification (P<0.001), PLR (P<0.001), and metastasis at initial diagnosis (P=0.002). Kaplan-Meier analyses revealed that tumor size (P<0.001), mitotic counts (P<0.001), Ki 67 labeling index (P<0.001), PLR (P<0.001), metastasis at initial diagnosis (P=0.031), and CD55 expression (P<0.001) were statistically significant risk factors affecting PFS of patients with gastric GISTs. Cox multivariate survival analysis showed that mitotic counts, Ki 67 labeling index, and CD55 expression were independent predictors of PFS for gastric GISTs. Conclusion: CD55 may be a potential prognostic marker in gastric GISTs patients.

Giant gastric stromal tumor mimicking as a posterior mediastinal mass: A case report and literature review

RATIONALE

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Mediastinal GISTs are rare and mostly arise from the esophagus.

PATIENT CONCERNS

A 68-year-old woman with dysphagia who presented with a huge posterior mediastinal mass.

DIAGNOSES

The patient was diagnosed with a GIST through chest computed tomography (CT)-guided core biopsy of the mass.

INTERVENTIONS

Complete excision including the tumor, lower part of the esophagus and fundus of the stomach were performed.

OUTCOMES

On follow-up after 48 months, the patient is currently alive without any evidence of tumor recurrence.

LESSONS

The case highlights GISTs are taken into consideration in the differential diagnosis of posterior mediastinal masses.

Gastrointestinal Stromal Tumors: Clinical Symptoms, Location, Metastasis Formation, and Associated Malignancies in a Single Center Retrospective Study

BACKGROUND AND AIMS

Gastrointestinal stromal tumors (GISTs) are rare malignancies but the most common mesenchymal tumors of the digestive tract. Recent advances in diagnostic imaging and an increasing incidence will confront us more frequently with stromal tumors. This single center study aimed to characterize GIST patients in terms of tumor location, clinical presentation, metastasis formation, as well as associated secondary malignancies.

METHODS

In a retrospective study, 104 patients with a histologically confirmed diagnosis of GIST, collected between 1993 and 2011, were characterized for several clinical features.

RESULTS

The most common GIST location was the stomach (67.6%) followed by the small intestine (16.2%). Gastrointestinal bleeding (55.8%) and abdominal pain (38.5%) were the most frequently reported symptoms whereas about one-third of patients remained clinically asymptomatic (31.6%); 14.4% of patients had either synchronous or metachronous metastases and there was a significant prevalence also in the low risk group. The proportion of secondary malignant associated neoplasms was 31% in our GIST cohort, among which gastrointestinal, genitourinary tumors, and breast cancer were the most prevalent.

CONCLUSION

There was a considerable risk for metastasis formation and the development of secondary neoplasias that should encourage discussion about the appropriate surveillance strategy after surgery for GIST.

Comparison Analysis of Three Different Types of Minimally Invasive Procedures for Gastrointestinal Stromal Tumors ≤5 cm

OBJECTIVE

This study aimed to evaluate the safety, feasibility, and prognosis of three different types of minimally invasive procedures for treating gastric gastrointestinal stromal tumors (GISTs) ≤5 cm.

MATERIALS AND METHODS

The clinical data, perioperative conditions, and the follow-up results of patients who underwent laparoscopic resection (LAP), laparoscopic and endoscopic cooperative surgery (LECS), or endoscopic submucosal dissection (ESD) for gastric GISTs ≤5 cm were retrospectively collected and analyzed.

RESULTS

A total of 91 patients were enrolled in this study, and the number of cases who underwent LAP, LECS, and ESD was 30, 15, and 46, respectively. Compared with patients in the LAP and LECS group, patients in the ESD group had a smaller tumor size (P < .001, <.05, respectively.) and a higher percentage of intragastric growth pattern (all P value <.01). Significant differences were found in operative time and intraoperative blood loss among the three groups (P < .001). The operative time and intraoperative blood loss in ESD group were significantly less than that in LECS and LAP groups. No statistical difference was found in the postoperative recovery and complications among the three groups, such as nasogastric tube retention, anal exhaust time, oral intake, postoperative complication, and tumor recurrence.

CONCLUSIONS

Minimally invasive surgery for gastric GISTs ≤5 cm is safe and feasible. The final choice regarding a minimally invasive approach should be based on the tumor size, tumor location, pattern of tumor growth, and experience of laparoscopic surgeons.

Atypical presentation of a gastric stromal tumor masquerading as a giant intraabdominal cyst: A case report

Gastrointestinal stromal tumors (GISTs) are mesenchymal neoplasms that arise in the gastrointestinal tract, accounting for ~1% of gastric malignancies. The present study reports the case of a GIST of the stomach in a 75-year-old man who presented with abdominal distension and anorexia for 1 month. Gastroscopy was unremarkable. Ultrasound and computed tomography (CT) scans showed a giant intraabdominal cystic lesion of unknown origin. The lesion was initially believed to be a duplication cyst, a pancreatic pseudocyst or a liver cyst in the pre-operative diagnosis. Exploratory laparotomy revealed a cystic lesion of the lesser sac originating from the lesser curvature of the stomach. A distal gastrectomy with en bloc resection of the lesion was performed. The intraoperative frozen section showed a spindle-cell GIST and microscopically negative margins. The patient was treated with imatinib for 1 year. The latest CT scan at 14 months post-surgery did not show any recurrence. Although GISTs presenting as predominantly cystic lesions are very rare, they should be considered in the differential diagnosis of cystic lesions of the upper abdomen.

An innovative procedure of laparoscope combined with endoscopy for gastrointestinal stromal tumor resection and cholecystectomy: A case report and literature review

The present study reports a novel approach to laparoscopic and endoscopic cooperative surgery for gastric gastrointestinal stromal tumor (GIST) resection and cholecystectomy, and conducts a review of the associated literature. The novel surgical procedure was performed on one patient who was diagnosed with a GIST and cholecystic polypus. The GIST was resected using an insulation-tipped diathermic electrosurgical knife under the guide of an endoscope. Subsequently, a cholecystectomy was performed by inserting two more 5-mm trocars and instruments transumbilically, guided using an endoscope. The tumor and the gallbladder were exteriorized using a peroral approach and the incision lining of the stomach was sutured laparoscopically. The procedure was successfully performed and the patient experienced no discomfort during the 5-year follow-up. In conclusion, the present study demonstrates that laparoscopic and endoscopic cooperative surgery is feasible and would be an ideal choice for invisible abdominal scar surgery, in particular for multi-visceral resection.

Robotic management of gastric stromal tumors (GIST): a single Middle Eastern center experience

BACKGROUND

Surgical resection is the gold standard treatment for gastrointestinal stromal tumors (GISTs). This paper describes the authors' experience in the management of posterior gastric wall GISTs through the robotic surgical approach.

METHODS

A case-series analysis for surgically resected GISTs was conducted between 2009 and 2010. All patients were followed up until mid-2015.

RESULTS

Robotic resection was performed in four cases. There was no evidence of bleeding or leak in all cases. The median hospital length of stay was 8 (5-8) days. No post-operative morbidity or mortality was reported during the follow-up duration (mean ± SD; 40.25 ± 35 months).

CONCLUSION

Findings show that the robotic assisted surgical approach to the removal of posterior wall gastric stromal tumors is associated with 100% disease-free survival rate. Copyright © 2016 John Wiley & Sons, Ltd.

Robot-assisted resection of gastrointestinal stromal tumors (GIST): a single center case series and literature review

BACKGROUND

Robotic techniques are claimed to be an alternative to laparoscopic and open approaches for gastrointestinal stromal tumors (GIST) treatment. Our aim is to present our single center experience and a literature review.

MATERIALS AND METHODS

From June 2012 to August 2014, six patients with preoperative diagnosis of GIST were treated by robotic surgery at Sanchinarro University Hospital.

RESULTS

Two GIST tumors were localized in the second part of the duodenum, one in the first portion, two in the gastricantrum and another in the angular notch. Surgical procedures performed were two subtotal gastrectomies, one gastric wedge resection and three duodenal enucleations. None of the interventions needed conversion to open surgery. Mean operative time was 245 min (150-540). Mean hospital stay was 10.5 days (6-24). All lesions had microscopically negative resection margins. Mean follow-up was 24 months (8-33) with a disease-free survival rate of 100%.

CONCLUSIONS

A robotic approach for GIST tumors is a safe and feasible procedure with a well-accepted oncological surgical result. Copyright © 2015 John Wiley & Sons, Ltd.

Clinical Control Study of Endoscopic Full-thickness Resection and Laparoscopic Surgery in the Treatment of Gastric Tumors Arising from the Muscularis Propria

BACKGROUND

Gastric stromal tumors arising from the muscularis propria are located in deeper layers. Endoscopic resection may be contraindicated due to the possibility of perforation. These tumors are therefore usually removed by surgical or laparoscopic procedures. This study evaluated the curative effects, safety and feasibility of endoscopic full-thickness resection (EFR) of gastric stromal tumors originating from the muscularis propria.

METHODS

This study enrolled 92 patients with gastric stromal tumors >2.5 cm originating from the muscularis propria. Fifty patients underwent EFR, and 42 underwent laparoscopic intragastric surgery. Operation time, complete resection rate, length of hospital stay, incidence of complications, and recurrence rates were compared in these two groups.

RESULTS

EFR resulted in complete resection of all 50 gastric stromal tumors, with a mean procedure time of 85 ± 20 min, a mean hospitalization time of 7.0 ± 1.5 days and no complications. Laparoscopic intragastric surgery also resulted in a 100% complete resection rate, with a mean operation time of 88 ± 12 min and a mean hospitalization period of 7.5 ± 1.6 days. The two groups did not differ significantly in operation time, complete resection rates, hospital stay or incidence of complications (P > 0.05). No patient in either group experienced tumor recurrence.

CONCLUSIONS

EFR technique is effective and safe for the resection of gastric stromal tumors arising from the muscularis propria.